OR3-5 | Valve-in-Valve Transcatheter Aortic Valve Replacement: Incidence, Predictors, and Clinical Implications of Permanent Pacemaker Implantation – A Mayo Clinic Study (2012-2022)

Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) is an alternative to repeat surgery for malfunctioning bioprosthetic aortic valves. ViV-TAVR can have higher rates of prosthesis-patient mismatch and coronary obstruction compared to native valve TAVR. TLimited data exists for ViV-TAVR patients requiring permanent pacemaker implantation (PPI). This study aims to assess PPI occurrence, related factors, and clinical consequences in ViV-TAVR procedures conducted at the Mayo Clinic between 2012 - 2022. We retrospectively analyzed ViV-TAVR recipients using t-tests and chi-square tests for continuous and categorical variables. Adjusted odds ratios (aOR) were calculated to identify PPI-related factors, with significance set at p < 0.05. We included 237 patients without prior PPI who underwent ViV TAVR from 2012 to 2022. Of these, 77.6% were male, with a mean age of 77.2 years, and 10.1% had PPI. PPI rates were comparable between newer balloon-expandable and self-expandable valves (12.4% vs. 9.4%, p = 0.5). Mean valve diameters were statistically similar in both groups (24.5 mm vs. 24.4 mm, p = 0.4). However, the depth of the TAVR implantation beneath the prosthesis ring was greater in the PPI group (6.3 vs. 4.4 mm, p = 0.015). Multivariable logistic regression identified postprocedural ECG factors linked to higher PPI likelihood: LBBB (OR 21.3, 95% CI 4.5–99.6, p < 0.001), RBBB (OR 27.1, 95% CI 4.7–40.4, p < 0.001), and bi-fascicular block (OR 15.2, 95% CI 1.9–28.4, p = 0.01). Preprocedural ECG bi-fascicular block predicted PPI (OR 13.2, 95% CI 3.7 – 47.7, p < 0.001). Aortic stenosis (OR 4.8, CI 95% 1.8 – 13.2, p = 0.002) and combined aortic regurgitation/stenosis (OR 6.9, CI 95% 1.4 – 20.5, p = 0.035) were the TAVR procedural indications associated with PPI. Although PPI appeared to increase mortality during follow-up (OR 1.66, CI 95% 0.7 – 3.9, p = 0.249) after adjusting for age and sex, this was not statistically significant. In our study, the incidence of PPI in ViV-TAVR was 10%. Deeper ViV TAVR implantation was associated with PPI. Baseline ECG features such as bi-fascicular block and postprocedural ECG findings like LBBB, RBBB, and bi-fascicular block were linked to a higher probability of PPI.